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Home , Opium, Polish heroin

2018

A. REPORT

Global cultivation 37% Global seizures 10% 10% 579% change from previous year change from previous year imate est WORLD nt e c e 418,000 ha r 586,000 x t

s

o m 658 91 65 = tons tons tons opium heroin morphine 2017 2016 Global production 65% Global number of users change from previous year s ser u id 700–1,050 io p 9,100–9,400 tons o 34,3 million rs 10,500 tons tons of heroin se u processed produced e of opium t a into heroin i

p o 1,100-1,400 tons 19.4 million consumed as opium 2017 2016 Note: All data refer to 2016 except cultivation and production, which refer to 2017 (preliminary). EMBARGOED26 JUNE 2018 UNTIL The global area under opium Global opium production increased by 65 per cent cultivation increased by more than to 10,500 tons in 2017, the highest level since a third in 2017, while global opium UNODC started estimating global opium produc- production increased by almost two tion on an annual basis at the beginning of the thirds 11 AM EDT (5twenty-first PM century. CEST)1 The surge in global production primarily reflects an 87 per cent increase in opium The total area under opium poppy cultivation production in to a record high of 9,000 worldwide is estimated to have increased by some tons, equivalent to 86 per cent of estimated global 37 per cent to almost 420,000 ha from 2016 to 2017, primarily reflecting an increase in the cultiva- 1 Opium production estimates have existed since the proceed- tion of opium poppy in Afghanistan. With 328,000 ings of the Shanghai Opium Commission in 1909. Such ha under opium poppy cultivation, Afghanistan estimates were, however, based on different methodologies (such as payment of taxes and other levies by opium farm- accounted for more than three quarters of the esti- ers) and thus may not be fully comparable with the data mated global area under illicit opium poppy presented since UNODC started estimating global opium cultivation in 2017, a record level. production in 2000 (largely based on remote sensing and scientific yield surveys). The previous estimates included By contrast, opium poppy cultivation in , 16,600 tons of opium calculated for the year 1934, based on official reports by the (UNODC, “A cen- the country with the world’s second largest area tury of international drug control” (2009)), and 41,600 tons under opium poppy cultivation (accounting for 10 of opium for the period 1906/07, based on data reported by per cent of the global estimated area in 2017), the International Opium Commission (Report of the Inter- national Opium Commission, Shanghai, , February 1 to declined over the period 2015–2017 by some 25 February 26, 1909). For more details, see the online meth- per cent to 41,000 ha, the lowest level since 2010. odological annex of this report.

12 ANALYSIS OF DRUG MARKETS A. Opioids 3

Record increase in opium poppy cultivation in Afghanistan: future challenges

The record level of opium poppy cultivation in Afghani- Moreover, the transformation of opium into heroin is stan in 2017 is likely to create multiple challenges for likely to bring increased trafficking of precursor sub- the country, neighbouring countries and the many other stances, which will potentially be diverted from licit countries of transit and destination for Afghan . international markets and smuggled into Afghanistan Afghanistan is one of the least developed countries in to supply manufacturers of heroin. More high-quality, the world, and the impact of illicit drug cultivation and low-cost heroin will reach consumer markets across the production on economic, environmental and social devel- world, with increased consumption and related harms opment continues to be multifaceted. Increased levels being the likely consequence. Only a small share of the of opium poppy cultivation, opium production and illicit revenues generated by the cultivation and trafficking of trafficking of opiates will exacerbate the harmful effects Afghan opiates reaches Afghan drug trafficking groups. of the existing large-scale production of opiates and Many more billions of dollars are made from trafficking are likely to fuel further instability and insurgency and opiates into major consumer markets, mainly in Europe increase funding to terrorist groups in Afghanistan. The and Asia. Addressing the problem in Afghanistan expanding illicit economy, which in many provinces has is therefore a shared responsibility. permeated rural societies and made many communities dependent on income from opium poppy cultivation, will Source: UNODC and the Ministry of Counter- of further constrain the development of the licit economy Afghanistan, Afghanistan Opium Survey 2017: Cultivation and potentially fuel corruption. and Production (Vienna, 2017), p. 7.

opium production in 2017. The increase in produc- manufacture to date has increased far less than tion in Afghanistan was not only due to an increase opium production.3 in the area under poppy cultivation but also to Of the 10,500 tons of opium produced worldwide improving opium yields. There is no single reason in 2017, it is estimated that some 1,100–1,400 tons for the massive increase in opium poppy cultivation remained unprocessed for consumption as opium, in Afghanistan in 2017 as the drivers are multiple, while the rest was processed into heroin, resulting complex and geographically diverse, and many ele- EMBARGOEDin an estimate UNTIL of between 700 and 1,050 tons of ments continue to influence farmers’ decisions 26 JUNEheroin manufactured2018 worldwide (expressed at export regarding opium poppy cultivation. A combination purity), 550–900 tons of which were manufactured of events may have exacerbated rule-of-law chal- in Afghanistan. lenges, such as political instability, corruption, a lack of government control and11 security. AM The shift EDT in In contrast(5 PM to the situation CEST) in Afghanistan, opium strategy by the Afghan Government — focusing its production in Myanmar decreased over the period efforts on countering anti-government elements in 2015–2017 by some 14 per cent to an estimated densely populated areas — may have made the rural 550 tons, equivalent to 5 per cent of the global population more vulnerable to the influence of opium production estimate. Despite this decline, anti-government elements. A reduction in the the opium price fell by almost 30 per cent to $153 engagement of the international aid community per kg in Myanmar in 2017,4 and the quantity of may also have hindered socioeconomic development opiates seized also decreased, suggesting a decrease opportunities in rural areas.2 in demand for opiates produced in Myanmar. This may be linked to the massive expansion in the supply As a result of the massive increase in opium produc- tion in 2017, opium prices fell in Afghanistan by 3 Higher quality heroin prices were, in February 2018, still 47 per cent from December 2016 to December only 7 per cent lower than a year earlier. (Afghanistan, 2017. However, the price of high-quality Afghan Ministry of Counter-Narcotics and UNODC, “Afghanistan heroin decreased by just 7 per cent over the same drug price monitoring monthly report” (February, 2018)). 4 Also, only limited data on opium prices could be collected period, which may be an indication that heroin by the opium survey field team in Myanmar in 2017, which may potentially impact on the findings (Myanmar, Central 2 Afghanistan, Ministry of Counter-Narcotics and UNODC, Committee for Drug Abuse Control and UNODC, Myan- Afghanistan Opium Survey 2017 (Vienna, 2017). mar Opium Survey 2017, p. 16.).

13 2018

Fig. 1 Opium poppy cultivation and production of opium, 2006–2017a REPORT 11,000 440,000 10,000 400,000

DRUG 9,000 360,000 8,000 320,000 7,000 280,000 on on (tons) WORLD

ti 6,000 240,000 on (hectares) on

5,000 200,000 ti va ti

Produc 4,000 160,000

3,000 120,000 Cul 2,000 80,000 1,000 40,000 0 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Total area under cultivation Production in Afghanistan Production in Myanmar Production in the Lao People's Democratic Republic Production in Production in other countries

Source: UNODC, calculations are based on UNODC illicit crop monitoring surveys and the responses to the annual report questionnaire. a Data for 2017 are still preliminary. Mexico is not included in 2016/2017 due to the lack of data.

of even lower priced Afghan opiates in 2017.5 If Another factor in the decline in the heroin price confirmed, this would constitute a new phenomenon could be a decrease in the demand for opiates as there is no prior evidence of changes in Afghan resulting from a switch to the use of ATS and other opium production impacting on opium prices in synthetic in the subregion. South-East Asia, or vice versa, as the two markets While Canada is mainly supplied with heroin from have mainly existed in isolation from each other. South-West Asia,6 countries in Latin America EMBARGOED(mostly UNTIL Mexico and, to a far lesser extent, Fig. 2 Global opium production and and Guatemala) account for most of the heroin quantities of opioids seized,26 2006–2017JUNE 2018 supply to the while also supplying the 10,000 250 still small heroin markets of South America. How- ever, there are no opium production estimates for 8,000 200 Mexico for the years 2016 and 2017, as the meth- on on (tons) 11 AM EDT (5 PM CEST) ti 6,000 150 odology for such estimates is currently under review. du c 4,000 100 Opiate seizures increased to record levels in 2016 and continue to be 2,000 50 Opioids seizuresOpioids (tons) Opium Opium pro concentrated in Asia 0 0 The total quantity of heroin seized globally reached 2016 2017 2015 2013 2014 2012 2011 2009 2010 2008 2007 2006 a record high in 2016, while the quantities of opium Opium production and morphine seized reached the second highest Seizures of morphine Seizures of heroin level ever reported. The largest quantities of opiates Seizures of opium (in heroin equivalents) seized were of opium (658 tons), followed by sei- Pharmaceutical opioids zures of heroin (91 tons) and morphine (65 tons). Source: UNODC, responses to the annual report questionnaire; Overall seizures of opiates, expressed in heroin and government sources. equivalents, increased by almost 50 per cent from Note: A ratio of 10:1 was used to convert opium into heroin equiva- lents. 2015 to 2016, of which the quantity of heroin seized exceeded that of opium and morphine. 5 Myanmar, Central Committee for Drug Abuse Control and UNODC, Myanmar Opium Survey 2017, p. 16. 6 UNODC, responses to the annual report questionnaire.

14 ANALYSIS OF DRUG MARKETS A. Opioids 3

Fig. 3 Countries reporting largest quantities of opiates seized, 2016 Opium Morphine Heroin Iran (Islamic 528,928 Afghanistan 47,048 16,34823,172 Republic of) Iran (Islamic Iran (Islamic Pakistan 64,608 Republic of) 10,903 Republic of) 16,11621,098 Afghanistan 49,665 Pakistan 6,596 China 8,777 4,903 Myanmar 472 United States 7,173 China 3,104 China 97 5,585 United States 1,7 76 Mexico 50 Bahrain 5,438 Uzbekistan 1,447 India 29 Afghanistan 4,588 Myanmar 1,005 Colombia 28 India 1,683 612 United States 12 Azerbaijan 1,186 Turkey 337 Italy 10 France 1,080 Russian Turkmenistan 293 Sweden 4 Federation 966 Mexico 226 Canada 3 Egypt 816 Other 1,057 Other 4 Other 9,277 10,000 20,000 30,000 40,000 50,000 10,000 20,000 400,000 200,000 Seizures (kilograms) Seizures (kilograms) Seizures (kilograms)

Source: UNODC, responses to the annual report questionnaire; and government sources.

As most seizures of opiates are made in, or close to, cent), while 6 per cent was seized in East and South- the main opium production areas, Asia, which is East Asia. responsible for more than 90 per cent of global illicit Quantities of heroin and morphine seized opium production, accounted for 86 per cent of the are on the increase in South-West Asia but total quantity of heroin and morphine seized in on the decrease in South-East Asia, Europe 2016. This is primarily a reflection of the increasing and the Americas concentration of opium production in Afghanistan and the consequent increase in seizures by neigh- The quantity of heroin and morphine intercepted bouring countries. EMBARGOEDin Asia more UNTIL than doubled from 2015 to 2016 to 26 JUNEreach 135 2018 tons. This reflected increases in the Near Similarly to the distribution of heroin and morphine and Middle East/South-West Asia of more than 150 seizures, overall, 90 per cent of the total quantity of per cent (mostly in countries neighbouring Afghani- opiates (including opium), expressed in heroin stan), a consequence of marked increases in Afghan equivalent, was seized in Asia,11 the vastAM majority EDT in opiate (5 production. PM CEST)By contrast, the quantities of the Near and Middle East/South-West Asia (83 per heroin and morphine seized in East and South-East Asia decreased by 6 per cent in that period, which Fig. 4 Distribution of global quantities of can be linked to the decline in opiate production in heroin and morphine seized in 2016 Myanmar and thriving ATS trafficking in the (N= 156 tons) subregion. Near and Middle East/ South-West Asia 76% In Europe, the quantity of heroin and morphine seized fell by 32 per cent, to 11 tons, from 2015 to 2016, the smallest quantity seized since 1997, Americas 6% Asia reflecting a decrease of 11 per cent in West and 86% Europe East and , a decrease of 31 per cent in South- 7% South-East , and a decrease of 67 per cent in Africa Asia 7% 1% Eastern Europe. Other Asia Oceania 3% In 2016, the quantity of heroin and morphine seized 0.2% in the Americas decreased, for the first time in years, Source: UNODC, responses to the annual report questionnaire; by 22 per cent, mostly in North America (-25 per and government sources. cent). Nevertheless, almost 90 per cent of all heroin

15 2018

Fig. 5 Quantities of heroin and morphine per cent of the total quantity of heroin and mor- REPORT seized, in kilograms, for selected regions, phine seized worldwide in 2016, with a further 4 2006–2016 per cent seized by countries in Western and Central

DRUG 140,000 Europe. Most of the heroin and morphine seized 120,000 on the Balkan route was seized in the Islamic Repub- lic of Iran (32.0 tons), while smaller quantities were

WORLD 100,000

il ograms seized in Turkey (5.6 tons), the Balkan countries 80,000 (0.8 tons) and the countries of Western and Central 60,000 Europe (3.9 tons). Opiates are trafficked either along the eastern branch of the Balkan route from Turkey

Seizuresk in 40,000 to and then onwards to and Hun- 20,000 gary, or along the western branch of the Balkan route 0 from Bulgaria to various western Balkan countries,

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 and from there to countries in Western and Central Asia Europe Americas Europe. Source: UNODC, responses to the annual report questionnaire; The analysis of all countries of origin, departure and and other government sources. transit of seized heroin and morphine reported by and morphine intercepted in the Americas was seized West and Central European countries in the annual in North America, which is home to both the main report questionnaire over the period 2012–2016 heroin manufacturing country in the Americas revealed that 80 per cent of all heroin-related men- (Mexico) and the main consumption country tions were linked to countries along the Balkan route. (United States). The decline in the quantity of A further 6 per cent were linked to Pakistan. While heroin seized in North America has taken place in some heroin is trafficked directly from Pakistan by the context of the rapidly growing market for syn- air or sea to Europe, large opiate shipments are also thetic opioids, such as and its analogues trafficked from Pakistan to the Islamic Republic of smuggled into the United States, as reflected in the Iran for onward trafficking along the Balkan route. doubling of the quantityEMBARGOED of “pharmaceutical opioids” The UNTILIslamic Republic of Iran reported that 80 per seized in North America in 2016.26 Overall, JUNE 25 per cent 2018 of the morphine and 85 per cent of the heroin cent of fentanyl seizures in the United States also it seized in 2016 had been trafficked into the coun- contained heroin in 2016 and were often sold as try via Pakistan, with the rest being smuggled directly heroin.7 from Afghanistan. It should be highlighted, though, 11 AM EDT (5that significantPM CEST) amounts of Afghan opiates remain The quantity of heroin seized in Africa increased by in the region for local consumption. 46 per cent from 2015 to 2016, but was still 85 per cent lower than at its peak in 2014. Much smaller amounts of heroin are trafficked along a sub-branch of the Balkan route that goes from the The Balkan route continues to dominate the trafficking of opiates Islamic Republic of Iran to the countries of the originating in Afghanistan southern Caucasus (mainly Azerbaijan and Georgia) for shipment across the Black Sea to Ukraine and The world’s principal heroin trafficking route con- then by land, partly through the Republic of Mol- tinues to be the so-called Balkan route, along which dova, to Romania for onward trafficking along the opiates are trafficked from Afghanistan to the Islamic eastern branch of the Balkan route to Western Republic of Iran, Turkey, the Balkan countries and Europe. According to seizure data, opiate trafficking then on to various destinations in West and Central along this sub-branch of the Balkan route increased Europe. Excluding seizures made in Afghanistan, considerably for several years, with seizures of heroin countries along the Balkan route accounted for 37 and morphine rising from 121 kg in 2006 to 1.3 tons in 2016. However, 2016 seizure data for this 7 United States, Department of Justice, Drug Enforcement Administration, 2017 National Drug Threat Assessment route indicate diverging trends: heroin and mor- (October 2017). phine seizures increased sharply in Azerbaijan and

16 ANALYSIS OF DRUG MARKETS A. Opioids 3

Fig. 6 Percentage distribution of quantities of shipment to Europe or North America (mostly heroin and morphine seized, by main a Canada). Overall, 9 per cent of mentions of coun- trafficking route tries of origin, departure and transit of opiate seizures 100 90 by reporting European countries were linked to 80 opiate trafficking along the southern route over the 70 period 2012–2016. In 2016, two European coun- 60 tries reported trafficking of heroin via the southern 50 40 route: Belgium (10 kg, via Kenya) and Italy (65 kg, 30 via the United Arab Emirates and via Qatar). 20 10 Heroin supply to the Russian Federation

(pcercentage) - continues to transit Central Asia and (pcercentagte) 2006 2008 2010 2012 2014 2016 Transcaucasia AmericasAmericas South-EastSouth-East Asia Asia and and Oceania Oceania Trafficking to the Russian Federation is carried out NorthernNorthern route route predominantly along the northern route via the SouthernSouthern route route countries of Central Asia, or via the countries of the Proportion of global heroin and morphine seized and morphine seized of global heroin Proportion Proportion Proportion of global heroin and morphine seized PakistanPakistan BalkanBalkan route route Caucasus, to destination markets in the Russian WestWestern and andCentral Central Europe Europe Federation and, to a very small extent, for traffick- AfghanistanAfghanistan ing onwards to Belarus and Lithuania.8 In 2016, SeizuresSeizures involving involving Afghan Afghan opiates opiates the main transit countries for heroin seized in the Source : UNODC, responses to the annual report question- Russian Federation continued to be countries in naire. Central Asia and Transcaucasia (notably Tajikistan, a Balkan route: the Islamic Republic of Iran—South-Eastern Europe—Western and Central Europe; the southern route: South Kazakhstan and Azerbaijan), while Pakistan, which Asia—Gulf countries and other countries in the Near and Middle had been mentioned as a transit country in 2015, East—Africa; northern route: Central Asia and Transcaucasia—East- ern Europe. was no longer a major country of transit. Despite indications of a decrease in heroin Georgia in 2016 but declined sharply in Ukraine trafficking in East and South-East Asia, the and Romania, which couldEMBARGOED be an indication of a subregion UNTIL remains the main source of greater opiate supply through the countries26 ofJUNE the heroin 2018to Oceania Caucasus that goes undetected, or it could be an indication that increased law enforcement opera- Opiates produced in South-East Asia (mostly Myan- tions in the countries of the Caucasus have prevented mar) are trafficked to other markets in that subregion much of the onward trafficking11 toAM Ukraine EDT and (mostly (5 ChinaPM and CEST) ) and to Oceania Romania. Most of the heroin seized in Romania in (mostly ). Seizures made in those countries 2016 had transited Turkey and Bulgaria, in contrast decreased by 15 per cent in 2016. In Australia, nearly to the situation reported in 2015, when most heroin all heroin quantities intercepted at the border in transited Ukraine. 2015 originated in South-East Asia (98 per cent over the period January–June 2015), but trafficking Quantities of heroin trafficked directly to of heroin may be declining as suggested by seizures Western and Central Europe via the south- at the border which, in terms of both quantities and ern route may be on the decrease cases, decreased from 2014/15 to 2015/16.9 Some Afghan opiates are trafficked to Europe Heroin trafficking in the Americas is through the so-called southern route, which goes on the decrease, while the trafficking of from Afghanistan to Pakistan (and partly to the synthetic opioids is on the increase Islamic Republic of Iran) for subsequent shipment to the Gulf countries and East Africa and onward Most heroin (and morphine) trafficked in the Amer- trafficking to Europe, either directly by air or via icas is smuggled from Mexico to the United States, Southern or West Africa by air or sea. Alternatively, 8 UNODC, annual report questionnaire data. drugs are trafficked along the southern route to India 9 Australian Criminal Intelligence Commission, Illicit Drug and other countries in South Asia for subsequent Data Report 2015-16 (Canberra, 2017).

17 - 2018 CANADA REPORT DRUG OCEANIA

WORLD ASIA SOUTH-EAST LAO PDR THAILAND CHINA MYANMAR INDIA

TAJIKISTAN KYRGYZSTAN PAKISTAN KAZAKHSTAN AFGHANISTAN ASIA CENTRAL UZBEKISTAN ISLAMIC OF IRAN TURKMENISTAN REPUBLIC & MIDDLE EAST EAST GULF AREA

CAUCASUS AFRICA RUSSIAN FEDERATION KENYA TURKEY (UNITED TANZANIA REPUBLIC OF) BULGARIA AFRICA SOUTHERN ALBANIA NIGERIA Lorem ipsum Lorem NETHERLANDS WESTERN, CENTRAL AND SOUTH EASTERN EUROPE WEST AFRICA EMBARGOED26 JUNE 2018 UNTIL

11 AM EDT (5 PM CEST) SOUTH AMERICA COLOMBIA NORTH AMERICA CANADA OF AMERICA UNITED STATES GUATEMALA MEXICO Main heroin trafficking flows, 2012–2016 Main heroin

Most frequently mentioned Most frequently countries of seized provenance/transit in Latin America opiates produced mentioned Most frequently countries of seized provenance/transit in Myanmar/Lao opiates produced Democratic Republic People’s mentioned Most frequently countries of seized provenance/transit in Afghanistan opiates produced INDIA PAKISTAN, Global heroin trafficking flows by size of trafficking Global heroin flows estimated on the basis of reported 2012-2016: seizures, Sources: UNODC, responses to annual report questionnaire and individual drug seizure database. and individual drug seizure questionnaire to annual report UNODC, responses Sources: Notes: The size of the trafficking flow lines is based on amount heroin seized in a subregion and number mentions countries from where has departed (including reports ‘origin’ transit”) to specific over 2012-2016 period. A darker shade indicates that country represents more than 50 percent of heroin production in the region. The trafficking flows are determined on basis country of origin/departure, transit and destination seized drugs as reported by Member States in the annual report questionnaire individual drug seizure database: such, they need to be considered as broadly indicative of existing trafficking routes while several secondary flows may not be reflected. Flow arrows represent the direction of trafficking: origins indicate either area manufacture or one last provenance, end points either the area of consumption or one next destination trafficking. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. dotted line represents approximately Line of Control in Jammu and Kashmir agreed upon Indi a Pakistan. final status and Kashmir has not yet been agreed upon by the parties. The final boundary between the Republic of Sudan and South has not yet been determined. A dispute exists Governments Argentina United Kingdom Great Britain Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). Map 1 of countries from where the heroin has departed (including reports of "origin" Notes: The size of the trafficking flow lines is based on amount heroin seized in a subregion and number mentions countries from where has departed (including reports "origin" Ireland concerning sovereignty over the Falkland Islands (Malvinas). and "transit") to a specific subregion over the period 2012–2016. A darker shade indicates that country represents more than 50 per cent of heroin production in the region. The trafficking flows are ed and Northern and the Republic of South Sudan has not yet been determined. A dispute exists between Governments Argentina Unit ed Kingdom Great Britain Northern determined on the basis of country of origin/departure, transit and destination seized drugs as reported by Member States in the annual report questionnaire individual drug seizure database: such, cate either the area of manufacture or one last provenance, end points arrows indicate consumption next destination trafficking. they need to be considered as broadly indicative of existing trafficking routes while several secondary flows may not be reflected. Flow arrows represent the direction of trafficking: origins indi Sources: UNODC, responses to the annual report questionnaire and individual drug seizure database. and individual drug seizure questionnaire to the annual report UNODC, responses Sources: of Control in Jammu and Kashmir agreed upon by India Pakistan. The final status has not yet been agree d the parties. boundary between the Republic of Sudan undetermined boundaries. The dotted line represents approximately the Line The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. dotted line represents approximately Line

18 ANALYSIS OF DRUG MARKETS A. Opioids 3

with far smaller quantities smuggled from Colombia Fig. 7 Estimated number of opiate users, and Guatemala. Analysis of heroin samples in the trends in quantities of heroin seized United States over the past decade shows the increas- and heroin and opium use perception ing predominance of Mexico (90 per cent of samples indexes (2006=100) analysed in 2015) as a source country of the drug, 30 300 while the importance of countries in South America 25 200 (3 per cent) has declined markedly. South-West Asia 20 100 accounted for around 1 per cent of the samples ana- lysed in 2015.10 15 0 Based on quantities seized, heroin trafficking in the 10 -100 Americas, particularly trafficking to North America, 5 -200 16 .5 18 .1 17 .4 16 .2 16 .8 16 .5 16 .4 16 .5 17 .3 17 .7 19 .4 showed a clear upward trend until 2015, ending 0 -300

with a marked decline in 2016. This seems to have users (millions) Number of opiate 2015 2016 2014 2012 2013 2011 2009 2010 2008 gone in parallel with an expansion in the trafficking 2006 2007 Estimated number of opiate users (2006 = 0) Opiate use perception index of synthetic opioids in the region, as some organized Trends in quantities of heroin seized crime groups from Mexico and, to a lesser extent, Heroin use perception index from the Dominican Republic that are involved in Opium use perception index heroin trafficking expanded their activities to the Source: UNODC, elaboration based on annual report question- trafficking of synthetic opioids, notably fentanyl.11 naire data. The global opiate market is on the the prevalence of opiate use has been increasing, increase again with the increase being particularly marked in 2016. The latest data on the number of annual opiate users The 2016 increase was primarily the result of higher suggest that there has been an expansion of the opiate use estimates reported by , reflecting global opiate market, with 19.4 million users in not only rising prevalence rates for heroin use (from 2016, or 0.4 per cent of the population aged 15–64 0.1 per cent of the population aged 15-64 in 2014 years. More than half of the estimated number of to 1.1 per cent in 2016) but also high levels of EMBARGOED UNTIL 12 annual opiate users reside in Asia (5826 per cent),JUNE “” 2018 use (1.7 per cent). Also known as almost one fifth in Europe (17 per cent), and one “”, “kompot” is a liquid preparation seventh in the Americas (15 per cent). The highest made from , which is intended for opiate prevalence rates were reported in the Near injecting. In West and Central Europe as a whole, and Middle East/South-West Asia (1.6 per cent), 12 countries reported stable trends in heroin use in North America (0.8 per cent)11 and EuropeAM (0.6 EDT per 2016, (5 two PMreported aCEST) decline and three an increase cent). While both quantities of heroin seized and (up from one in 2015). the prevalence of opiate use are on the increase at In parallel, there have been reports of rising drug-re- global level, the heroin use perception index, based lated deaths in various European countries in recent on assessments by national experts, has remained years, often linked to the use of opiates, although relatively unchanged in the past few years. the ageing of drug-using cohorts may also have Signs of increases in the opiate market in played a role. In England and Wales, for example, West and Central Europe -related deaths rose by more than 58 per cent over the period 2012–2016 to 2,593 cases, with The downward trend in opiate use since the late heroin- and morphine-related deaths doubling over 1990s observed in Western and Central Europe that period.13 In Germany, where opiates are respon- appears to have come to an end in 2013. Since then 12 UNODC, data from replies to UNODC annual report 10 United States, Department of Justice, Drug Enforcement questionnaire. Administration, 2017 National Drug Threat Assessment 13 United Kingdom of Great Britain and Northern Ireland, (October 2017), p. 48. Office for National Statistics, “Deaths related to drug poi- 11 Drug Enforcement Administration, 2017 National Drug soning in England and Wales: 2016 registrations”, Statistical Threat Assessment. Bulletin (Newport, 2 August 2017).

19 2018

Fig. 8 Prevalence of opiate use in Western Fig. 9 First time entrants into drug-related

REPORT and Central Europe, 2006–2016 treatment per 100,000 inhabitants in 0.7 the Russian Federation, by drug type, 2006–2017* DRUG 0.6 20 19.0 20.7 0.5 18.6 17.7 17.4 WORLD 0.4 15.3 14.5

15 14.1 13.9 12.6

0.3 11.2 11.1 10

0.2 18.3 16.7 16.1 15.2 14.5

0.1 5 12.2 10.5 7.7 7.2 64 15– on aged (percentage) years 6.1 ti 4.2 3.6 0 per 100,000 inhabitants 0 Prevalence rate of opiate use among useamong Prevalenceopiate rate of pu la 2014 2015 2016 2006 2007 2008 2009 2010 2011 2012 2013 First time entrants into treatment po 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

West andWestern Central and Europe Central - prevalence Europe – prevalenceTrend Other drugs and combinations Psychostimulants Source: UNODC, elaboration based on annual report question- naire data. Cannabinoids Opioids sible for the bulk of all drug-related deaths, the All first time entrants to drug related treatment Source: “Basic Functioning Indicators of the Narcological Ser- number rose from 944 deaths in 2012 to 1,333 vice of the Russian Federation”. Set of statistical handbooks deaths in 2016.14 for 2008–2017, released by NRC on – branch of By contrast, heroin seizures have not increased in V.Serbsky NMRCPN. *Data for 2017 are still preliminary. Western and Central Europe in recent years and actually decreased in 2016. The conflicting trends opioids over time. Drug-related deaths in the Rus- between demand indicators and seizures could be sian Federation, which are mostly linked to the use the result of different dynamics; for example, an of opioids, fell from 9,354 cases in 2006 to 5,249 increased supply of high-purity opiates (explained cases in 2016, the lowest level in a decade.15 by larger production inEMBARGOED Afghanistan) could go unde- Mixed UNTIL signals from the opiate market in tected yet drive a rise in demand and26 related JUNE health North 2018 America consequences. In the Americas, expert perceptions suggest an The opiate market in Eastern Europe increase in heroin use in recent years. The largest continues to shrink heroin market in the Americas is the United States, In Eastern Europe, the 11heroin perceptionAM EDT use index (5accounting PM for CEST)almost 80 per cent of all opiate users remained largely stable from 2006 to 2016, while in the region and 86 per cent of all opiate users in heroin seizures have been declining along the north- North America. National household surveys and ern route, the main trafficking route from heroin-related deaths suggest that heroin use has Afghanistan to Eastern Europe, suggesting a shrink- been increasing for some time in the United States. ing of the opiate market in the subregion. While the estimated number of heroin users rose by 14 per cent in 2016 (from the previous year), the In the Russian Federation, the most important annual prevalence rate of heroin use doubled opiate market in Eastern Europe, the drug market between 2010 and 2016. The increase in heroin- has started to change, and other drugs, particularly related deaths was primarily linked to heroin being synthetic drugs, have started to dominate. The combined with fentanyl.16 number of first time entrants into treatment for opioid use (mostly heroin use) declined by more 15 “Basic Functioning Indicators of the Narcological Service than three quarters over the period 2006–2017, with of the Russian Federation”. Set of statistical handbooks for a reduction in the proportion of drug treatment for 2008-2017,released by NRC on Addictions – branch of V.Serbsky NMRCPN. 16 Centers for Disease Control and Prevention, Heroin over- 14 Germany, Bundeskriminalamt, Rauschgiftkriminalität: Bun- dose data, 2018. Available at www.cdc.gov/drugoverdose/ deslagebild 2016 (and editions of the previous years). data/heroin.html.

20 ANALYSIS OF DRUG MARKETS A. Opioids 3

On the other hand, workforce testing results showed Fig. 10 Heroin prevalence rate in student and a small decrease in heroin use in 2016, from 0.28 household surveys, and heroin-related per cent in 2015 to 0.25 per cent of the federally deaths in the United States, 2006–2016 mandated workforce and the general workforce of 5.0 1.0 17 the United States that were tested. The annual 4.0 0.8 adjusted)

prevalence of heroin use among young adults - remained relatively stable in 2016 (0.4 per cent in 3.0 0.6 2016 compared with 0.5 per cent in 2015),18 while the annual prevalence of heroin use among eighth, 2.0 0.4 related deaths per (percentage) - tenth and twelfth grade students in the United States 1.0 0.2 continued to decrease in 2016 (from 0.8 per cent Heroin

in 2010 to 0.3 per cent in 2016) and remained at 0.0 0.0 Annual prevalence of heroin use the lower level in 2017.19 100,000 population (age 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Heroin-related deaths Heroin use appears to be on the increase Heroin-related deaths in Africa Annual prevalence of heroin use among 12th graders AnnualAnnual heroinprevalence prevalence of heroin of heroin use use among among the 12th general graders population aged 12 years and older Information on the prevalence of opiate use in Africa Annual prevalence of heroin use among the general population and in Asia is still very limited, making it difficult Annualaged 12 prevalenceand older of heroin use among the general populationAnnual prevalence aged 18–25of heroin years use among the population aged 18- to identify solid trends. Based on expert perceptions 25 Source: United States, and Mental Health Ser- reported to UNODC, heroin use in Africa appears vices Administration, Center for Behavioral Health Statistics and to have increased more than in other regions over Quality, Results from the 2016 National Survey on Drug Use and Health: Detailed Tables (Rockville, Maryland, September 2017); the period 2006–2016, likely reflecting the increas- and Centers for Disease Control and Prevention, Multiple cause ing “spillover” effect of heroin trafficking from of death database, December 2016; and “ deaths South-West Asia along the southern route. Increases in the United States, 1999–2016”, NCHS Data Brief (December 2017). in the use of heroin in East Africa were reported in 2015 by Kenya and the United Republic of Tanza- Declines in heroin use in 2016 were mainly reported nia and in 2016 by Madagascar; in southern Africa in countries in East and South-East Asia, notably by Mozambique in 2015; andEMBARGOED in West and Central China (Hong UNTIL Kong Special Administrative Region), Africa by Côte d’Ivoire in 2016. In 2016,26 several JUNE Indonesia, 2018 the Republic of Korea and Thailand. By large African countries reported a stabilization in contrast, several countries in the Near and Middle heroin use — notably all of the North African coun- East/South-West Asia reported increases in 2016, tries, Nigeria in West and Central Africa, South notably Iran (Islamic Republic of), Iraq, Qatar and Africa and Zambia in Southern11 Africa, AM and KenyaEDT the United(5 PM Arab Emirates CEST) (and, in 2015, Pakistan). in East Africa. In the rest of Africa, expert percep- These increases could be linked to increasing levels tions point to a decline in heroin use in the region of heroin trafficking from Afghanistan to those following several years of ongoing increases. countries. However, other countries, including In Asia, data on expert perceptions suggest a decline Israel, Jordan and Saudi Arabia, where in heroin use since 2011, particularly since 2014. play a larger role, saw heroin use stabilize. Most countries in Central Asia do not yet seem to 17 This is based on some 9 million drug tests made of work- have been affected by the increase in Afghan heroin ers of the federally mandated workforce and the general manufacture; experts perceived declines in heroin workforce in the United States in 2015 and 2016 (Quest use in 2016 in Uzbekistan, Kyrgzystan and Kazakh- Diagnostics Drug Testing Index, full year 2016 tables (May, 2017) and results of the previous year). stan. This is in line with reports of decreasing 18 John Schulenberg and others, Monitoring the Future quantities of heroin seized along the northern route National Survey Results on Drug Use, 1975-2016: 2016— in Central Asia in recent years. College Students and Adults Ages 19-55, vol. 2 (Ann Arbor, Michigan, University of Michigan, 2017), p. 49. Heroin use in Oceania remains limited 19 National Institute of Drug Abuse, Monitoring the Future survey, 2017 data from in-school surveys of 8th, 10th and In Oceania, expert perceptions suggest a slight 12th grade students. decline in heroin use in the past five years. Annual

21 2018

Fig. 11 Trends in heroin use perception index, the prevalence of use of , ATS and synthetic REPORT by region (2006 = 100) cannabinoids. Among the various opioids, the preva- 125 lence of heroin use in New Zealand ranked third

DRUG 120 after pharmaceutical opioids and after opium. 115 The market for non-medical use of 110

WORLD pharmaceutical opioids is expanding 105 100 Despite the paucity of data in many subregions, the 95 trafficking of and the non-medical use of pharma- 90 ceutical opioids seem to be of increasing concern 85 for both law enforcement agencies and public health professionals in many countries, although the extent 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Heroin use perception index(2006=100) and type of pharmaceutical opioids used for non- Africa Americas Asia Europe Oceania medical purposes may differ. In North America, for example, , , and Source: UNODC, responses to the annual report questionnaire. are the main pharmaceutical opioids that are used for non-medical purposes, while metha- prevalence data for Australia, which accounts for done, and fentanyl are the main the majority of heroin users in Oceania, showed a pharmaceutical opioids misused (based on drug decline in heroin use from a peak of 0.8 per cent of treatment services data)23 reported in Europe. In the population aged 14 years and older in 1998 to countries in West Africa, North Africa and the Near 0.2 per cent in 2001 and 0.1 per cent in 2013, before 20 and Middle East, tramadol is the main substance increasing to 0.2 per cent in 2016. This pattern used by people reporting non-medical use of phar- is confirmed by a number of other indicators that maceutical opioids. showed a massive decline in heroin supply and use in 2001 and no significant recovery thereafter.21 Seizures of pharmaceutical opioids have Wastewater analysis in 2017 confirmed low levels reached similar levels to those of heroin of overall heroin consumptionEMBARGOED in Australia, possibly In 2016, UNTIL the global quantity of pharmaceutical opi- a consequence of comparatively 26very high JUNE heroin oids 2018 seized was 87 tons, roughly the same as the prices (AUD 33522 or $263 per gram in 2017). quantity of heroin seized that year. The largest quan- Elsewhere in the region, heroin use in New Zealand tities of pharmaceutical opioids seized in 2016 were, was reported to be low and stable, with opioid preva- once again, of tramadol (68 tons), followed by lence being lower, as in11 most otherAM countries, EDT than (5codeine PM (18 tons), CEST) oxycodone (1 ton) and fentanyl (0.4 tons). The quantities of pharmaceutical opioids 20 Australian Institute of Health and Welfare, National Drug seized, other than tramadol, and hydro- Strategy Household Survey 2016 (Canberra, 2017). morphone, increased in 2016. The increases were 21 Australian Institute of Criminology, “Australian heroin particularly pronounced in the case of codeine and drought affects heroin market”, Crime Facts Info, No. 12 (20 November, 2001); Louisa Egenhardt, Carolyn Day and oxycodone, which rose more than thirtyfold from Wayne Hall, The Causes, Course and Consequences of the previous year, as well as in the case of fentanyl the Heroin Shortage in Australia, Monograph Series, No. and its analogues (carfentanyl, a tenfold increase; 3 (Sydney, University of New South Wales, National Drug and Research Centre, 2004); Louisa Degenhardt and fentanyl, a fourfold increase) and of buprenor- and others, “Evaluating explanations of the Australian phine (a sevenfold increase). ‘heroin shortage’”, , vol. 100 (2005), pp. 459– 469; Anne Dray and others, “Policing Australia’s ‘heroin Africa continues to dominate global drought’: using an agent-based model to simulate alterna- seizures of pharmaceutical opioids tive outcomes”, Journal of Experimental Criminology, vol. 4, No. 3 (2008), pp. 267–287. In 2016, the largest quantities of pharmaceutical 22 A. Karlsson and L. Burns, Australian Drug Trends 2017: opioids were seized, for the second year in a row, by Findings from the Illicit Drug Reporting System (IDRS), Australian Drug Trend Series, No. 181 (Sydney, University of New South Wales, National Drug and Alcohol Research 23 EMCDDA, European Drug Report 2017: Trends and Devel- Centre, 2018), p. 39. opments.

22 ANALYSIS OF DRUG MARKETS A. Opioids 3

African countries (mostly in West and Central Fig. 12 Trends in the use of heroin and Africa, and North Africa), accounting for 87 per prescription opioids in the United cent of the global total. Asia accounted for just 7 States, 2002–2016 per cent of the global total of pharmaceutical opioids 1,000 14,000 seized in 2016 (mostly East and South-East Asia). 12,000 800 The pharmaceutical opioids seized in Africa con- 10,000 sisted mainly of tramadol, followed by codeine. In 600 8,000 Asia, seizures of pharmaceutical opioids were domi- 400 6,000 nated by codeine, followed by tramadol, while in 4,000 (thousands) Europe they were dominated by tramadol, followed (thousands) 200 2,000 by methadone and codeine. Large tramadol seizures

0 0 Number of persons reporting in Europe were made in Malta and Greece, of trama- medical use of prescription opioids Number of persons who used heroin 2002 2004 2006 2008 2010 2012 2014 2016 dol that originated in India and was destined for - non Heroin; past-year use markets in North Africa. Seizures of pharmaceutical Heroin; past-month use opioids in the Americas were dominated by oxyco- Prescription opioids; past-year use done, followed by codeine and fentanyl. Prescription opioids; past-month use Comparisons of seizures of pharmaceutical opioids Source: United States, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics by weight can mask the fact that very different num- and Quality, Results from the 2016 National Survey on Drug bers of doses can be obtained from 1 gram of Use and Health: Detailed Tables (Rockville, Maryland, Septem- different opioids. Expressed in terms of doses seized, ber 2017). rather than of weight seized, seizures of pharmaceu- in the past five years. The most commonly misused tical opioids in the Americas were clearly dominated prescription opioids reported in the National Survey by fentanyl and its analogues in 2016, followed by on Drug Use and Health in 2016 in the United oxycodone. Even at the global level, calculations States are hydrocodone, oxycodone, codeine and based on doses recommended for medical use24 by tramadol. While the non-medical use of fentanyl first-time users suffering from suggest that most self-reported in that survey is minimal (0.1 per cent doses of pharmaceutical opioidsEMBARGOED seized in 2016 were of the population UNTIL aged 12 years and older), illicit of fentanyl, followed by codeine.25 26 JUNEfentanyl 2018 and its analogues are increasingly found in Fentanyl and its analogues remain a major the analysis of drug samples, including of heroin.27 concern in the United States Illicit fentanyl is reportedly mixed into heroin as well as other illicit drugs such as “ecstasy”, or sold In the United States in 2016, nearly 4 per cent of 11 AM EDTas counterfeit (5 PM prescriptions CEST) opioids. Since users are the population aged 12 years and older reported often unaware of the contents of the substance or non-medical past-year use of prescription opioids,26 tablet they are taking, this can lead to fatal overdose which was most prevalent among those aged 18–25 incidents.28 years. Compared with heroin use, which has been increasing each year since 2007, the non-medical There were almost 64,000 overdose deaths in the use of prescription opioids has shown a stable trend United States in 2016, with deaths accounting for over 70 per cent of the total. While 24 The British National Formulary recommends doses of 50 all opioid related deaths have increased in the United mg of tramadol, 30 mg of oxycodone, 5 mg of codeine or States, the most worrying trend is the number of 0.1 mg of fentanyl to patients suffering from pain who had overdose deaths related to synthetic opioids, which not taken pain before. (British National Formu- lary, vol. 74 (September 2017-March 2018)). doubled in the past year. Synthetic opioids include 25 Detailed calculations are provided in the online methodo- fentanyl, fentanyl analogues and tramadol. logical annex. 26 United States, Substance Abuse and Mental Health Services 27 United States Department of Justice, Drug Enforcement Administration, Center for Behavioral Health Statistics and Administration, “Emerging threat report: fourth quarter Quality, Results from the 2016 National Survey on Drug Use 2017”. and Health: Detailed Tables (Rockville, Maryland, Septem- 28 Drug Enforcement Administration, 2017 National Drug ber 2017). Threat Assessment.

23 2018 concerning concerning REPORT AND AUSTRALIA NEW ZEALAND DRUG WORLD ASIA EAST AND SOUTH-EAST ASIA SOUTH AND CENTRAL ASIA TRANSCAUCASIA NEAR AND MIDDLE EAST EUROPE EASTERN EUROPE AFRICA SOUTH-EAST SOUTHERN AND EUROPE CENTRAL WESTERN NORTH AFRICA , WHO Technical Report Series, No. 902 (Geneva, World Health Organization, 2002); United States Health Organization, 2002); United States Report Series, No. 902 (Geneva, World , WHO Technical WEST (2017) (and previous years). International Narcotics Control Strategy Report (2017) (and previous AFRICA EMBARGOED26 JUNE 2018 UNTIL

11 AM EDT (5 PM CEST) SOUTH AMERICA (and previous years); report of Heads of National Law Enforcement Agencies for Agencies for of Heads National Law Enforcement years); report Report of the International Narcotics Control Board for 2016 (and previous CENTRAL AMERICA NORTH AMERICA Reported tramadol seizures (and/or misuse) and major tramadol trafficking/diversion flows, 2012–2016 Reported tramadol seizures Reported trafficking flows of tramadol originating in India Reported trafficking flows of tramadol originating in China Reported trafficking flows of tramadol via transit countries Reported trafficking < 1 kg > 1 - 10 kg > 10 - 100 kg > 100 - 1,000 kg > 1,000 - 10,000 kg > 10,000 kg and/or misuse Reported seizures

Annual tramadol seizures Sources: UNODC, annual report questionnaire data, International Narcotics Control Board, Report 2016 (and previous years), Heads of National (HONLEA) report 2016 (and previous years), World Health Organisation, Expert Committee on Drug Dependence, years), World 2016 (and previous Agency (HONLEA) report years), Heads of National Law Enforcement Report 2016 (and previous Board, data, InternationalControl questionnaire Narcotics UNODC, annual report Sources: years). Strategy Report 2017 (and previous Control International Narcotics Affairs, for Internationaland Law Enforcement Thirty-sixth Meeting, Geneva, 16-20 June 2014, Bureau Narcotics The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. dotted line represents approximately Line of Control in Jammu and Kashmir agreed upon Indi a Pakistan. final status Kashmir has not yet been agreed upon by the parties. The final boundary between the Republic of Sudan and South has not yet been determined. A dispute exists Governments Argentina United Kingdom Great Britain Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). Department of State, Bureau for International Narcotics and Law Enforcement Affairs, for International and Law Enforcement Department of State, Bureau Narcotics Map 2 resent undetermined boundaries. The dotted line represents approximately Notes: The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines rep resent undetermined boundaries. dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India Pakistan. The final status has not yet b een parties. boundary between the Republic Source: UNODC, annual report questionnaire data, questionnaire UNODC, annual report Source: sovereignty over the Falkland Islands (Malvinas). of Sudan and the Republic South has not yet been determined. A dispute exists between Governments Argentina United Kingdom Great Britain Northern Ireland  2016 (and previous years); WHO Expert Committee on Drug Dependence: Thirty-sixth Report 2016 (and previous

24 ANALYSIS OF DRUG MARKETS A. Opioids 3

Fig. 13 Non-medical past-year use of different opioids in their national drug use surveys, in the prescription opioids in the United States, countries that do so, such use ranges between 2.6 by age group, 2016 per cent of the adult population (Czechia) and 0.1 5 per cent (Latvia, Estonia and the United Kingdom). 4 Since 2009, 25 new opioids (mostly fentanyl and 3 its analogues) have been reported in the subregion. Although new opioids currently represent only a 2 fraction of the opioid market in Western and Cen- tral Europe, the new fentanyl analogues are highly of the population 1 potent substances that pose a serious threat to indi- 0 vidual and public health. Illicit fentanyl has been Annual Annual prevalence pecerntage as Overall 12–17 years 18–25 years 26+ years sold in the subregion on online markets and illicit Hydrocodone Oxycodone Tramadol local markets and sold as, or mixed with, heroin and Codeine Morphine Fentanyl 30 Buprenorphine Methadone counterfeit opioids.

Source: United States, Substance Abuse and Mental Health Heroin remains the most common opioid used in Services Administration, Center for Behavioral Health Statistics Western and Central Europe, but there are increas- and Quality, Results from the 2016 National Survey on Drug Use and Health: Detailed Tables (Rockville Maryland, September ing signs of misuse of pharmaceutical opioids in the 2017). subregion. In 2015, 17 countries reported that more than 10 per cent of all opioid users entering treat- Fig. 14 Opioid overdose deaths in the United States ment services did so for disorders related to use of opioids other than heroin. Opioids reported by 25,000 treatment entrants included methadone, buprenor- 20,000 phine, fentanyl, codeine, morphine, tramadol and oxycodone.31 In some countries, pharmaceutical 15,000 opioids such as fentanyl (Estonia) and buprenor- 10,000 phine (Finland) have been the most frequently misused opioid for some time. In Czechia, although

Number of deaths EMBARGOED UNTIL 5,000 26 JUNEheroin remains2018 the most frequently misused opioid, 0 other opioids make up over half of the share of all 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Heroin Fig. 15 Annual prevalence of non-medical use Morphine, oxycodone11 and hydrocodne AM EDT (5 ofPM pharmaceutical CEST) opioids in European Fentanyl, fentanyl analogues and tramadol countries, 2016 or the latest year Source: United States, Centers for Disease Control and Preven- 3 tion, National Center on Health Statistics, CDC WONDER, 2.5 2017. 2 Signs of use of pharmaceutical opioids emerging in Western and Central Europe 1.5 1 In Western and Central Europe, the non-medical use of pharmaceutical opioids is not at the same 0.5 level as that reported in North America, but the 0 Annual Annual prevalence (percentage)

emergence of new synthetic opioids (mostly fentanyl Italy Latvia Finland Estonia Czechia 29 United Kingdom

and its derivatives) is of concern in the subregion. Germany Although few countries in Western and Central Source: UNODC, based on responses to the annual report Europe report the non-medical use of pharmaceutical questionnaire.

29 EMCDDA, European Drug Report 2017: Trends and Devel- 30 Ibid. opments. 31 Ibid.

25 2018

Fig. 16 Trends in fentanyl overdose deaths in in West and Central Africa and North Africa, from REPORT Estonia, 2008–2016 where some of it is trafficked onwards to a number 180 160 of countries in the Near and Middle East. DRUG 140 There is a range of pharmaceutical opioids that are 120 100 used non-medically in most regions. However, the

WORLD 80 non-medical use of tramadol is of particular concern 60 in Western and Northern Africa and in many 40 20 countries in the Near and Middle East. While 0 population-based estimates of their use are not Number of overdose deaths available in that subregion, treatment provision data 2008 2009 2010 2011 2012 2013 2014 2015 2016 suggest that the extent of the non-medical use of Source: Estonian causes of death registry, 2017. pharmaceutical opioids in these subregions is quite Note: In 2016, of 114 fentanyl overdose deaths in Estonia, 67 cases were attributed to 3-methylfentanyl, while the remaining high. Although fatal overdose deaths attributed to were attributed to carfentanyl, and . pharmaceutical opioids are small in numbers, many countries in the subregion also report them. In the opioids used among those entering treatment for United Arab Emirates, while tramadol was 32 opioid-use disorders. dominating by far the pharmaceutical opioids Although not to the same extent as in the United detected in people in treatment, the situation States, overdose deaths related to fentanyl and its changed over the period 2013-2015.36 Based on analogues are also reported in Western and Central urine analysis of people in treatment, although the Europe. Between November 2015 and February number of samples containing tramadol remains 2017, 23 deaths associated with furanylfentanyl were high, it has declined by half whereas the number of reported in Estonia (4 deaths), Finland (1), Ger- other opioids such as, morphine and codeine many (4), Sweden (12), United Kingdom (1) and doubled over the period 2013-2015. In 2015, 23 Norway (1).33 Similarly, from April to December overdose deaths attributed to pharmaceutical opioids 2016, 47 deaths attributed to acrylfentanyl were were reported in the United Arab Emirates.37 reported in DenmarkEMBARGOED (1 death), Estonia (3) and The UNTILfirst ever assessment of problem drug use in Sweden (43). Many of those deaths26 were JUNE reported Palestine 2018 in 2016 estimated that 1.8 per cent of the 34 among high-risk opioid users. male population aged 15 years and older were high- Non-medical use and trafficking of risk drug users. In Gaza, tramadol was the most tramadol is emerging as the main commonly used substance, followed by concern in several regions11 AM EDT (5benzodiazepines PM CEST) and . In the study sample of high-risk users, 97 per cent of Most of the tramadol seized worldwide in the period respondents in Gaza reported non-medical use of 2012–2016 originated in India and, to a lesser extent, tramadol, while in the West Bank, in China.35 Tramadol is smuggled to various markets

32 Ibid. INCB/2016/1) (and the Board’s annual reports for previ- 33 EMCDDA, Furanylfentanyl Report on the Risk Assess- ous years); Heads of National Law Enforcement Agency ment of N-phenyl-N-[1-(2-phenylethyl)piperidin-4-yl] (HONLEA) report for 2016 (and previous years); WHO furan-2-carboxamide (furanylfentanyl) in the Framework Expert Committee on Drug Dependence: Thirty-sixth Report, of the Council Decision on New Psychoactive Substances, WHO Technical Report Series, No. 902 (Geneva, World Risk Assessments (Luxembourg, Publications Office of the Health Organization, 2002); and Bureau for International European Union, 2017). Narcotics and Law Enforcement Affairs, International Nar- 34 EMCDDA, Acryloylfentanyl: Report on the Risk Assess- cotics Control Strategy Report 2017 (and previous years). ment of N-(1 phenethylpiperidin-4-yl)-N-phenylacrylamide 36 Abuelgasim Elrasheed and others, “Changing patterns of (acryloylfentanyl) in the Framework of the Council Deci- substance abuse: analysis of lab test results of a patient sion on New Psychoactive Substances, Risk Assessments cohort at the National Rehabilitation Center, Abu Dhabi, (Luxembourg, Publications Office of the European Union, UAE”, International Addiction Review, vol. 1, No. 1. 2017). (2017). 35 UNODC, annual report questionnaire data; Report of 37 Responses to the annual report questionnaire submitted by the International Narcotics Control Board for 2016 (E/ United Arab Emirates, 2015.

26 ANALYSIS OF DRUG MARKETS A. Opioids 3

Tramadol Tramadol is the generic name for an opioid , first bodies, particularly in Africaf and the Middle East,g have high- marketed by Grünenthal in 1977. It is used in the treatment lighted problems with the non-medical use of tramadol. In of moderate to severe pain. The analgesic effect is multi- 2017, the WHO Expert Committee on Drug Dependence modal and involves agonist activity at the μ- reportedh that there was growing evidence of misuse of tra- and adrenergic and serotonergic properties. The metabolite madol in many countries, accompanied by adverse reactions of tramadol, O-desmethyltramadol is primarily responsible and tramadol-associated deaths and recommended a critical for the agonist activity at the μ-opioid receptor, while the review of the substance. The UNODC early warning advisory parent compound acts as a serotonin releaser and inhibits the on new psychoactive substances has received reports of sei- reuptake of noradrenaline and serotonin, leading to mood zures of both tramadol and O-desmethyltramadol. enhancement. The usual oral doses of tramadol are 50 to 100 mg every 4 to a Martindale: The Complete Drug Reference, 38th ed. (London, 6 hours, with a maximum daily dose not exceeding 400mg.a Pharmaceutical Press, 2014). Tramadol may also be used orally as an extended-release or a b K. Miotto and others, “Trends in tramadol: , variable-release formulation, once or twice daily. Preparations metabolism, and misuse”, and Analgesia, vol. 124, of tramadol are also available for parenteral, rectal, sublingual No. 1 (2017), pp. 44–51. and intranasal administration. c WHO Expert Committee on Drug Dependence, “Tramadol: Tramadol is extensively metabolised in the liver following oral pre-review report”, Thirty-ninth Meeting, Geneva, 6–10 administration. The metabolic reaction to the active μ-opioid November 2017. agonist, O-desmethyltramadol, depends on the activity of d Joint Ministerial Statement of the 2014 high-level review by the hepatic enzyme CYP 2D6, which displays genetic poly- the Commission on Drugs of the implementation morphism in man. Slow metabolizers have relatively low by Member States of the Political Declaration and Plan of plasma concentrations of O-desmethyltramadol, whereas Action on International Cooperation towards an Integrated and rapid metabolizers have relatively high plasma concentra- Balanced Strategy to Counter the World Drug Problem (See tions of this active metabolite.b The corollary is a difference Official Records of the Economic and Social Council, 2014, in expression of the net effect of tramadol on mood and of Supplement No. 8 (E/2014/28), chap. I, sect. C). O-desmethyltramadol on the μ-opioid receptor. Of signifi- e Commission on Narcotic Drugs resolution 56/14 on strength- cance is the established body of knowledge that a number ening international cooperation in addressing the non-medical of medicines and drinks, such as grapefruit juice, can inhibit use and abuse, the illicit manufacture and the illicit domestic CYP 2D6 activity in man. InEMBARGOED fact, several internet drug-user and internationalUNTIL distribution of tramadol (2013). forums report on user experiences of combining26 JUNE tramadol f Commission 2018 on Narcotic Drugs resolution 56/2 on the Accra with grapefruit juice to preserve or enhance its mood-enhanc- declaration (2013). ing properties, at the expense of the O-desmethyltramadol g mediated analgesic effect. Commission on Narcotic Drugs resolution 59/2 on the out- comes of the meetings of the subsidiary bodies of the Commis- According to WHO,c tramadol can produce physical depen- sion on Narcotic Drugs, including the Abu Dhabi declaration dence, with studies showing that11 this dependenceAM EDT may occur (5(2016). PM CEST) when tramadol is used daily for more than a few weeks. h WHO Expert Committee on Drug Dependence: Thirty-ninth Since 2013, Member States, through several resolutions of the Report, WHO Technical Report Series, No. 1009 (Geneva, Commission on Narcotic Drugsd, e and its regional subsidiary World Health Organization, 2017).

were the most consumed substances, followed by Tramadol tablets available in some parts of Africa cannabis, anticonvulsants (mainly ) and are reportedly meant for the illicit market and may .38 be of a dosage higher than that normally prescribed for medical purposes. In Egypt, for example, the Many countries in West and Central Africa and authorities report the availability of 225 mg tablets North Africa (mostly Egypt) have reported large of tramadol on the illicit market, which are far quantities of tramadol seized; however, information stronger than the usual 50 mg tablets available for on the non-medical use of tramadol and other phar- pain relief and the slow-release tablets that range maceutical opioids in those subregions is limited. from a strength of 50 mg to 200 mg.39

38 Palestinian National Institute of Health and UNODC, Esti- 39 Egypt, General Secretariat of Mental Health of the Ministry mating the Extent of Illicit Drug Use in Palestine (November, of Health, “Report of the General Secretariat of Mental 2017). Health and Addiction Treatment on tramadol” (2017).

27 2018

REPORT Tramadol in Ghana, 2016–2017 Non-medical use of tramadol in Ghana was first identi- rape, abduction, murder and violence, among tramadol

DRUG fied by the authorities in 2016, leading to the opioid users and tramadol trafficking gangs, who often use being controlled at national level in that year. This machetes, broken bottles and other weapons in their resulted in the market for recreational use of tramadol confrontations. disappearing, at least temporarily, although, despite its WORLD Police raids on markets in the suburbs of Accra and use being limited to medical purposes, new incidences analyses of drugs seized by the laboratory of the Food of use of tramadol, which was being illegally imported, and Drug Authority of Ghana revealed that capsules of were observed in 2017. high tramadol content, far above the usual adult medical There are no hard data to help determine the magnitude dose (50–100 mg per capsule), are increasingly being of non-medical use of and trafficking in tramadol in sold. Most (40 per cent) of the 524,00 tramadol capsules Ghana, but qualitative reporting from authorities has seized and analysed in Ghana in 2017 had a content of identified this as a fast emerging threat. Tramadol has 120 mg of tramadol, 18 per cent had a content of 200 been found to be increasingly used by gang members, mg, and a further 19 per cent had a strength of 225 commercial vehicle drivers, women who work in mar- mg per capsule. Only a small portion (13 per cent) of kets who need to trade long hours and students trying the tramadol seized had a typical content for medical to keep awake during study periods. Tramadol is often purposes of 50–100 mg per capsule. About 87 per cent used together with energy drinks, alcoholic beverages of the tramadol seized in 2017 originated in India, while and marijuana, with users reporting taking tramadol to no country of origin could be identified for the remain- experience a feeling of , for extra energy or for ing quantities seized. It is, however, unclear whether aphrodisiac purposes. The authorities have identified the seized packages had been illicitly manufactured or increasing numbers of injuries and fatalities linked to diverted from licit manufacturing and where the diver- driving under the influence of tramadol; the recruitment sion took place. of young children as look-outs and drug peddlers; and overall increases in crime rates, including of drug-related crimes linked to other criminal activities, such as robbery, Source: Food and Drugs Authority, Ghana.

In Egypt, tramadol is reported to be the main opioid Fig. 17 Trends in the non-medical use of for non-medical use, EMBARGOEDwith an estimated 3 per cent UNTILpharmaceutical opioids and heroin of the population diagnosed with 26tramadol JUNE depend- 2018among persons in treatment in the ence in 2016. In drug treatment, tramadol is also United Arab Emirates, 2013–2015 the main drug reported, with nearly 68 per cent of 800 700 2013 drug treatment patients in 2017 being treated for 2014 600 tramadol use disorders. High levels of emergency 2015 room cases (fatal and non-fatal)11 AM attributed EDT to the (5 PM500 CEST) non-medical use of tramadol are also reported in 400 40 300 and reported and

Egypt. and reported 200 Also in Nigeria, the non-medical use of opioids is 100 Number of samples analyzed of concern. In 2016, cannabis (45 per cent) and Number of samples analysed 0 opioids (36 per cent) were the main substances, Codeine Morphine Heroin Tramadol excluding alcohol, for which people sought treat- Source: Abuelgasim Elrasheed and others, “Changing patterns ment for their drug use disorders. Most people of substance abuse: analysis of lab test results of a patient cohort at the National Rehabilitation Center, Abu Dhabi, UAE”, treated for opioid use disorders were misusing tra- International Addiction Review, vol. 1, No. 1. (2017). madol, codeine and .41

40 Ibid. 41 Nigeria, National Drug Law Enforcement Agency, “Patterns of drug and alcohol use in Nigeria” (2016).

28